Provider Demographics
NPI:1407327687
Name:CARREON, KIMBERLY MAE RUIZ (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY MAE
Middle Name:RUIZ
Last Name:CARREON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 ROUTE 340
Mailing Address - Street 2:
Mailing Address - City:SPARKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10976-1205
Mailing Address - Country:US
Mailing Address - Phone:845-596-1369
Mailing Address - Fax:
Practice Address - Street 1:161 FORT WASHINGTON AVE FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-305-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308369363LA2200X
NYF308369-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner